Gone with the wheeze OSCE by James Chua

 
You have 3 minutes reading time. This OSCE will run for a maximum of 7 minutes.

Scenario:

You have been asked by your resident to speak to the parent of Amy, a 4 year old child who is about to be discharged from the ED in the morning after a period of observation in ED overnight. The child's parent is concerned about what to do should the child deteriorate after discharge.

Amy is a 4yo child who is fully immunised. She suffers from intermittent but infrequent episodes of asthma 2-3 times a year and only uses a salbutamoI inhaler when needed. She currently has coryzal symptoms and was brought in overnight as she was too distressed to sleep with her wheeze. She has been treated overnight and your resident feels that she is ready for discharge.

Instructions for the candidate

Review the case with your resident to establish suitability for discharge, and provide Amy's parent with discharge advice as appropriate.

Domains being examined

  • Medical Expertise
  • Communication
  • Health Advocacy
  • Scholarship and Teaching
  • Professionalism
 
The candidate has 3 minutes reading time. This OSCE is expected to run for a maximum of 7 minutes.

For the actor

ED Resident:
You have been handed over this case from the overnight ED resident and have reviewed Amy and her progress in ED to date.
Amy has infrequent asthma attacks months apart.
She presented with moderate symptoms of asthma overnight - normal alertness, some accessory muscle use, RR 30 and SaO2 98% on RA. She was unable to perform a PEFR properly.
She received 3 doses of salbutamoI by inhaler and spacer during the first hour of her presentation and has not required any further inhaler treatment for the last 4 hours.

She has had breakfast and is watching a video on an iPad.

The Parent:
You have been up all night in the ED with your daughter and very tired. You were quite upset as Amy only suffers asthma infrequently and last night was the first time you have seen her so distressed. You feel that Amy may need more time in the hospital and you are worried that she might get worse if she goes home now. You don't know what to do if she gets wheezy again and want to be told what has been done so far to help Amy, and what to do if she gets worse. If reassured and educated appropriately, you are willing to take her home in more confident state of mind. You live 10 minutes away from the hospital.

For the examiner

Props: spacer, puffers, obs chart

Domains Assessment Objectives

Medical Expertise

Communication

Health Advocacy

Scholarship and Teaching

Professionalism

Other Assessment Notes

The candidate needs to first establish Amy's background asthma history and pertinent factors involving her current presentation to establish that she is indeed safe for discharge.

During conversation with the resident the candidate needs to ask questions to rule out high-risk features of asthma mandating inpatient care - eg. features suggestive of persistent asthma and/or a severe/critical exacerbation.

In communicating with the parent, a professional approach with clear explanation of treatments in ED, clinical progress during the period of observation and appropriate discharge advice including education about spacer use and representation criteria, proximity of home to hospital etc. need to be addressed.


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